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The Association between Late-life Depression and Medical Illness Maria D. Llorente MD Professor Dept. of Psychiatry & Behavioral Sciences Miller School of Medicine at the University of Miami

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The “Graying” of America  By the year 2025, the world’s older population (60 and older) will approach 1.2 billion.  By the year 2030, 1 of every 5 people in the U.S. will be 65 or older.  Older Americans will number more than 65 million

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U.S. Dept of Health and Human Services. Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, NIH, NIMH, Late-Life Depression Incidence of major depression declines with age, but minor depression is much more common Depressive symptoms occur in 15% – 25% of older adults (>65 years) that fail to meet criteria but cause distress and interfere with functioning Fewer than half of depressed seniors are recognized as being depressed and of those who are identified fewer than half receive treatment

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Primary Care is the De Facto Mental Health System (in the United States) responsible for the care of more patients with mental disorders than the specialty mental health sector. Regier et al. Arch Gen Psychiatry 1993; 50:85-94

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Major Depression and Diabetes Mellitus Medline and PsycINFO databases and published reference lists were used to identify studies that measured the association of depression with glucose control. A total of 24 studies satisfied the inclusion and exclusion criteria for the meta-analysis. Depression was significantly associated with hyperglycemia (Z = 5.4, P < ). Lustman et.al. Diabetes Care 2000 Jul;23(7):934-42

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Suicide and Lifetime Axis I Diagnosis By Age Suicide and Lifetime Axis I Diagnosis By Age Conwell, Am J Psychiatry, 1994

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Reasons for Underdiagnosis of Late-life Depression in Primary Care Over-identification with the patient Lack of time Lack of training in mental health False belief that older adults won’t respond to treatment Atypical symptoms in older adults

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* Must include 1 of these DSM-IV-TR. Washington, DC: American Psychiatric Association S leep: Insomnia or hypersomnia I nterest*:Depressed mood* Loss of interest* G uilt: Feelings of worthlessness E nergy: Fatigue C oncentration: Diminished ability to think or make decisions A ppetite: Weight change P sychomotor: Psychomotor slowing or agitation S uicide: Preoccupation with death  5 Symptoms in the same 2-week period DSM-IV-TR Criteria for Major Depression

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APA Practice Guidelines for the Treatment of Psychiatric Disorders Treatment Goal The goal of treatment with either antidepressant medication or psychotherapy in the acute phase is the remission of major depressive disorder symptoms

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Pseudodementia Patients may present with complaints of loss of memory Frequent “I don’t know responses” on exam Often a prodrome of dementing illness (as many as 50% may develop dementia within 5 years) If prodromal, usually late-onset, with prominent psychomotor retardation and/or psychotic features Consider frequent neurocognitive testing, and early use of cognitive-enhancing agents.

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Minor Depression Subsyndromal Depression Associated with significant functional impairment and disability, lower quality of life and increased medical care utilization Associated with progression to depression at one year follow-up DSM-IV-TR: qualitatively similar to major depression, but only 2-4 symptoms needed

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Caregiver Depression Often seen in those caring for older adult with dementia Associated with changing roles, increased responsibility, risk of social isolation, grief surrounding loss of demented person Often fail to recognize stress/burden, but report fatigue, insomnia, social withdrawal, and feeling “burned out” Affects quality of caregiving

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Caregiver Depression Barriers to open discussion: Need to protect themselves from feelings of disloyalty due to “complaining about” loved one May represent failure as caregiver Family already burdened with demented loved one, don’t want to add to burden Fear of own feelings of anger, guilt, ambivalence Need to approach from the perspective of enhancing the care provided

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Family Intervention and Nursing Home Placement Mittelman, JAMA 1996

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Keller MB, et al. Arch Gen Psychiatry. 1992;49: Hypotheses for Low Remission Rates in Major Depression Patients satisfied with incomplete response Patients, clinicians do not expect remission Treatments may not be well tolerated Physicians not comfortable or familiar with recommended optimal dosages

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Electro-convulsive therapy Indicated in patients who: Are acutely suicidal Have major depression with psychotic features Have failed 2 adequate trials of antidepressants Cannot tolerate antidepressant tx Have previously responded to ECT and prefer this tx Patients on average need 6-8 treatments

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General Principles of Late-life Depression Management Education for patient/family that meds are not effective until patient has taken them for the right amount of time (usually 3-6 weeks) in the right dose Start low, go slow, but go – need to reach therapeutic dose Minimum duration is 9-12 months after symptom remission for first episode Recommend long-term treatment in patients with 2 or more lifetime episodes

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Evidence-based Management of Late-life Depression Annual screening for depression in all patients Patients who screen positive are assessed within 6 weeks for a depressive disorder and/or suicidal ideas Those who assess positive require treatment with either therapy/ medication alone or in combination At least 3 follow-up visits within first 3 months Index episode treated for at least 9-12 months Recurrent episode maintained on antidepressant long- term